Foot Strike and Injury Rates in Endurance Runners

He Who Shouts Loudest…

…should be heard with a healthy dose of scepticism?

A heavily publicised study released by Dr. Daniel Lieberman and his team at Harvard University in January 2012, retrospectively evaluated the injury statuses of a mixed sex collegiate cross country running squad of 52 athletes.

Researchers classified each runner in terms of foot strike pattern:

Rear-foot (heel) strike

Forefoot strike

The injuries reported by runners in each the two groups were recorded and evaluated.

Purpose: This retrospective study tests if runners who habitually forefoot strike have different rates of injury than runners who habitually rearfoot strike.

Methods: We measured the strike characteristics of middle and long distance runners from a collegiate cross country team and quantified their history of injury, including the incidence and rate of specific injuries, the severity of each injury, and the rate of mild, moderate and severe injuries per mile run.

Results: Of the 52 runners studied, 36 (69%) primarily used a rear-foot strike and 16 (31%) primarily used a forefoot strike. Approximately 74% of runners experienced a moderate or severe injury each year, but those who habitually rear-foot strike had approximately twice the rate of repetitive stress injuries than individuals who habitually forefoot strike. Traumatic injury rates were not significantly different between the two groups. A generalized linear model showed that strike type, sex, race distance, and average miles per week each correlate significantly (p<0.01) with repetitive injury rates.

Conclusions: Competitive cross country runners on a college team incur high injury rates, but runners who habitually rearfoot strike have significantly higher rates of repetitive stress injury than those who mostly forefoot strike. This study does not test the causal bases for this general difference. One hypothesis, which requires further research, is that the absence of a marked impact peak in the ground reaction force during a forefoot strike compared to a rearfoot strike may contribute to lower rates of injuries in habitual forefoot strikers.

It turns out that 74% of the total group suffered significant running injury during the season – which roughly follows figures suggested by injury surveillance studies in endurance running.

The rear-foot (heel) strike group in this particular study suffered approximately double the rate of repetitive stress related running injuries, in comparison to the forefoot striking group.

MOST IMPORTANTLY PERHAPS:

This retrospective study focused on a very small sample size of elite level collegiate athletes. We almost certainly can’t make generalisations about the wider running population from such a small cross-section of a tiny niche within the top performance levels of our all-inclusive sport.

I mean, how can these results seriously be relevant to your typical middle aged 4hr marathon runner?!

The bold conclusions drawn from this particular piece of research have been wildly blown out of all proportion by some of those with a stake in the minimalist market (see this RunBlogger.com article).

Vivobarefoot even jumped onboard the propaganda train with this hastily released advert… enough said!

Fast-Forward to August 2013…

Thankfully, we now have additional recent research to hold alongside the study mentioned above, and those that preceded it. This additional data helps us to build a better understanding of the ‘big picture’ when it comes to the potential links between running foot-strike patterns and injury.

Grier et.al. (2013) With a sample size of 1332 soldiers, 17% of which were running in minimalist footwear, no significant injury rate differences were observed between minimalist and traditional running shoe wearing groups. Unfortunately we have to assume that runners in the minimalist group were mainly non-heel strikers.

In another study using Army subjects Warr et.al. (2013) however did assess the foot-strike pattern of each of their 342 participants. No significant difference was found between the injury rates and days training lost from injury, between the heel striking runners and non-heel strikers.

General Conclusion

The overall consensus to date seems to in fact be, that no reasonable link can be proven between running strike pattern and injury rates.

My Coaching Perspective

As a coach I’m not pro or anti forefoot striking, or indeed heel striking per se.

Both foot-strike patterns have their own merits and are appropriate for different types of runner.

The subject of running gait just isn’t that simple when you’re dealing with individual athletes and their individual dysfunctions, strengths and weaknesses.

In fact, some exciting (if you’re into that kind of thing – I am)recent research suggests that a percentage of runners who visibly heel strike actually experience maximal rate loading at the midfoot, not the heel!!

FYI

Personally, I’m a forefoot/midfoot runner myself, and can 100% claim to have benefitted from switching gradually away from a heel striking style – it works for me.

From anecdotal experience, I would suggest that habitual forefoot strikers, and well adapted ex-heel strikers tend to experience fewer knee (particularly Patellofemoral Pain Syndrome) injuries, perhaps due to the reduced peak knee flexion angle in mid stance. Something that my colleague Brad Neal and I have been discussing a lot recently…

The Harvard research cited above suggests that the impact peak in ground reaction force seen in the heel striking loading pattern may be more injurious. However, what’s so often not written about is how the impact peak cited in their study’s conclusion section can also be greatly reduced by staying within the heel strike classification as a runner, and simply landing the heel strike closer to under the centre of mass… without having to make such a wholesale change as moving onto the forefoot – which can lead to injuries in it self.

If I’m working with an athlete who is strong enough to maintain a forefoot position, had an appropriate injury history, and was training for a suitable distance – I’d definitely encourage them to adopt a forefoot position. However, if I did this with every athlete I work with, there’d be some very broken runners leaving my care!

More Research Needed

I’ll be very interested to see if anybody continues the injury surveillance and biomechanical research to sub-categorise heel strikers.

The categories could be:

Those who heel strike AND over-stride with a low cadence

Those who heel strike and maintain a contact closer to under their centre of mass through keeping a relatively high cadence. Therefore still experiencing less impact without going the whole way to a forefoot strike.

James has an academic background in Sport Rehabilitation and a special interest in Applied Biomechanics. He currently coaches a large number of Runners and Triathletes across all levels of ability and performance. He's grown a strong reputation for enabling athletes to improve their running performance and overcome running injuries through improving their Running Technique and developing Running Specific Strength.

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12 Comments

G’day James, You’re spot on with this analysis. Being a heel-striker is not necessarily such a bad thing. There are plenty of heel-strikers out there who can A. run very fast and B. do it without being injured. As you’ve suggested the Lieberman studies are useful but not the complete picture as they don’t look from the hips down. If this was measured we could better classify the heel-strikers by how well they activate their buttocks and hamstrings.

As an aside there are a number of forefoot strikers I have seen while coaching that do not activate their hamstrings and glutes quickly enough and therefore over-stride. Getting on your forefoot in this case isn’t all it’s cracked up to be and could possibly carry more risk of injury. Regards Brian

James, I agree with your assessments about being able to lower impact force of heel-strikers by changing stride, but not landing (fore/mid/heel). ALthough I’ll just point out that this was a retro-spective study without surveilance. The runners were not followed, simply evaluated and classified. Further research would then be based on these findings, or other hypothesis for prospective analysis. Some blinding by sports physicians and therapists would add to the value of future studies as well.

This article bring up some good points. I agree that the impact force is caused by over extending your legs not necessarily by landing on your heel. I think this is where cadence can come into play as well. If you keep a high cadence then you are more likely to not over extend your legs out in front of you.

Great article! I like how you acknowledge not all athletes are the same, and there is no “one-mechanics-fits-all”. Proper research is a very difficult thing to accomplish, so it’s always good to know it’s taken with a grain of salt, so to speak.

Quote: “The interesting part… the Rearfoot (Heel) Strike group suffered approximately double the number of repetitive stress related running injuries, in comparison to the Forefoot Strikers.”
End quote.

Frankly I am a bit surprised of that statement, because that is not very interesting and not very surprising as the rearfoot strikers of the example above provide with 59% almost the double number (in percentage) of the forefoot strikers (31%). I wonder what kind of “strikers” the remaining 10% were? (59 + 31 = 90, not 100) Or do I get my math wrong?

And there are still more rearfoot strikers out there than forefoot strikers. So more injuries in rearfoot strikers than in forefoot strikers come as no surprise to me…independently from research. Just applied common sense. Cheers. janedoemuc

Also in terms of the injuries reported. I’ve should have said “rate of repetitive stress related running injuries” rather than “number of repetitive stress related running injuries”. Makes far more sense now I hope!

That said, the sample size of this study is too small to read anything into the findings.

The whole aim of this blog post is to share my thoughts on the coaching relevance and application of such research – as per the discussion points added after the abstract.

[…] While recent research by Prof. Daniel Lieberman et al (2012), strengthens the argument that habitual forefoot and midfoot runners suffer fewer injuries and enjoy increased running efficiency, the findings need to be applied with caution. Read the following review of the new research to get my coaching perspective… […]

Hi James!
A simple question I have for you: What did you mean in your “FYI” that you feel benefited from a heel striking form? I didn’t quite get what that meant. Also, I am a collegiate runner and have been heel striking ever since I started running. I know for the fact that I can’t change my foot strike as much as the way my legs and muscles reacted to the impact. However, I have learned by trial that my legs adhere to minimalist shoes better than really supportive shoes due to my hips becoming over-used and over-striding. All thanks to these blog posts and some research.

Thanks Brad. I completely agree. Cadence is one of many great variables for many runners to focus on. As a primary intervention it is probalay the easiest for clients to take away and practice with confidence, using a metronome.

Good stuff – I’ve seen a number of articles that discuss this, and it’s quite clear that “where” you foot plant (under your center-mass) is more important than whether you’re a heel striker or mid-foot striker. Having a higher cadence and a better mechanically efficient stride is always a better way to approach good economy in running.